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New Student Medical Form

All information gathered from this form is held confidentially by the Office of Student Affairs. If you have any questions about this for or wish to discuss its contents in more detail please contact the Dean of Students. Telephone: +44 208 332 8208 E-Mail: colesta@richmond.ac.uk
This form is a required part of the admissions procedure. It must be completed to the best of your knowledge. The University may require students to produce supplementary information regarding medical conditions upon request.
1.Your full name: First, Middle & Last(Required.)
2.Date of Birth (Day/Month/Year):(Required.)
3.Nationality(Required.)
4.Religion
5.Sex(Required.)
6.Name, address and telephone number of a person who can be contacted in an emergency(Required.)
7.Relationship of this person to you
8.Please give us your emergency contact's personal email address.(Required.)
9.What is your height?(Required.)
10.What is your weight?(Required.)
11.How is your blood pressure?(Required.)
12.Have you been immunised for the following diseases within the last 5 years?(Required.)
Yes
No
Tetanus Toxoid
Poliomyelitis
BCG or Heaf
Rubella
Hepatitis B
Measles
Mumps
13.Are you currently taking any prescription medication?(Required.)
14.Have you ever had or been treated for any of the following?
Yes
No
Heart disease, high blood pressure, varicose veins or disease of the circulatory system
Diabetes, goitre or any disease of the glands
Epilepsy, fainting attacks or other disease of the brain or nervous system
Fistula, fissure, haemorrhoids or other disease of the rectum
Cancer, tumour, syphilis or tuberculosis
Asthma, pleurisy, or other diseases of the respiratory tract
Migraine headaches
Glandular fever
Any viral illness
Hepatitis
Malaria
Neck or back strain or hernia
Any deformity or loss of limb
Any disease of the reproductive organs
Psychological or psychiatric difficulties requiring treatment and/or medication
Emotional difficulties including depression, phobias or anxiety
Anorexia, bulimia or any other eating disorder
Ulcer or any disease of the stomach, intestines, gall bladder or other disease of the gastrointestinal tract
Arthritis, rheumatism, or other disease of the bones
Any impairment of sight, speech or hearing or any disease of the eye, ear, nose or throat
Any surgical operation/procedure performed or been advised to have performed during the past 5 years
Any substance abuse
Allergic reactions to food, environment or drugs
Any special dietary needs, preferences or difficulties
Menstrual problems including irregular, painful periods an/or premenstrual syndrome
Any other illnesses, diseases, or treatments not mentioned above during the past 5 years
15.Given the demands of the University environment and the location in London, do you feel you'll require any specific support during your studies?
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